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Please advise us if you need accommodations completing this application.

Full Name: *

Maiden Name/Alias (if applicable):

Address: *

City: *

State: *

Zip: *

I have been a resident of
*
for
*
years.

Home Phone: *

Cell/Beeper:

Alternate #:

Email Address:

I,
*
, understand scheduling assignments will be done via phone and/or email and agree to return calls placed to the number(s) listed above so as to confirm work schedule. Schedules will not be confirmed via email.

License/Certification #: *

State Issued:

*

Exp. Date: *

Do you maintain licensure from another state? *
No
Yes

If yes, which state?

I,
*
, understand it is a policy of NurSTAT to research and confirm all information regarding my license/certification via State Board of Nursing/Nurse Aide Registry, OIG and EPLS. To the best of my knowledge, the above information is correct and free from any legal implications.

Have you previously or currently have any malpractice claims and/or suits filed against you? *

No
Yes

If yes, please explain:

Are you at least 18 years old? *

No
Yes

Do you have access to transportation? *

No
Yes

Do you have a driver's license? *

No
Yes

Driver's License #:

State:

Exp. Date:

Have you been a resident of your state for at least two consecutive years? *

No
Yes

Have you been charged and/or convicted* of a crime, other than a traffic violation, within the last 7 years? *

No
Yes

If yes, please explain:

* Conviction will not necessarily disqualify applicant from employment

How were you referred to NurSTAT?

If referred by NurSTAT employee, please list name on line above

Next of Kin/Emergency contact:

Phone #:

Are you capable of performing the activities in the job for which you have applied? *

No
Yes

Education

High School *

School Name:

City:

State:

Graduated?

No
Yes
GED

College

School Name:

City:

State:

Degree/Major:

Graduated?

No
Yes
GED

Other

School Name:

City:

State:

Degree/Major:

Graduated?

No
Yes
GED

Previous Employment
list your 3 most recent employers:

Employer One *

Date From:

Date To:

Name of Employer:

Phone Number:

Supervisor:

Position:

Salary:

Reason for Leaving:

Employer Two *

Date From:

Date To:

Name of Employer:

Phone Number:

Supervisor:

Position:

Salary:

Reason for Leaving:

Employer Three *

Date From:

Date To:

Name of Employer:

Phone Number:

Supervisor:

Position:

Salary:

Reason for Leaving:

Personal References
Preferably co-workers; No Family

Reference One

Name

Phone Number:

Occupation:

Number of Years Known:

Did you, or are you currently working with reference?

No
Yes

Where?

Reference Two

Name

Phone Number:

Occupation:

Number of Years Known:

Did you, or are you currently working with reference?

No
Yes

Where?

Reference Three

Name

Phone Number:

Occupation:

Number of Years Known:

Did you, or are you currently working with reference?

No
Yes

Where?

*

I certify that answers given herein are true and complete to the best of my knowledge. I understand that, in the event of employment, false or misleading information given in my application or interview may result in discharge.

*

I authorize investigation of all references and statements contained in the application for employment, as they are necessary in arriving at an employment decision, and release all obligations to those individuals providing such reference.

*

I understand that after meeting all other job prerequisites, and after I am offered a job, employment will be contingent upon the satisfactory outcome of a medical examination and criminal background check.

*

I understand that if I am offered employment, I will be working for NurSTAT on it�™s payroll, and employment is based on client requests for staff relief. I have been made aware of the area NurSTAT provides supplemental service to, and that assignments will be offered based on our clients needs. I understand there are no guarantee of hours, that I am an at-will employee and employment may be terminated by NurSTAT or self at any time, without liability to me for wages and salary except as have been earned by me at the date of such termination.

Experience/Age Specific Competency

Directions: For each category, check box if you have experience, followed by the number of years�™ experience.

Please indicate number of years in which you have experience with the following:

Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level:A B C D E F G H I

Can ensure a safe environment reflecting specific needs of various age groups:A B C D E F G H I

Additional Credentialing

TYPE

CURRENT

EXPIRATION DATE

COMMENTS

CPR

Yes
No

First Aide Certification

Yes
No

BCLS

Yes
No

ACLS

Yes
No

IV Certification

Yes
No

PALS

Yes
No

Liability Insurance

Yes
No

Other:

Yes
No

Other:

Yes
No

List courses taken in addition to your license/certifications:

Criminal History Background Report

30-Day Provisional Hire Form/Affidavit

Agencies may employ applicants on a provisional basis for a single period not to exceed 30 days.

I, , have been a resident of for consecutive years.

PA Residents:

I, , swear and affirm that I have not been charged or convicted of any offenses contained
in Act 169 of 1996 as Amended by Act 13 of 1997 (see reverse) as outlined by the Commonwealth of Pennsylvania. The
effective date of the act is July 1, 1998.

I DO UNDERSTAND that a PA Criminal Record Check will be requested via PA State Police Criminal History Files.A fee of $10.00 will be deducted from my first paycheck.

FL Residents:

I, , swear and affirm that I have not been charged or convicted of any offenses contained
in Florida Statutes, Title XXXI Chapter 435 and Title XXIX Chapter 408.

I DO UNDERSTAND an FDLE Level II Criminal History Request will be completed via AHCA.A fee of $29.00 will be deducted from my first paycheck.

I DO NOTcurrently live out-of-state.

True
False

You may be required to obtain an FBI/FDLE Level II check. The office will notify you of such.

The following information is necessary when processing the background clearance:

Employee Name (Last, First Middle Initial):

Maiden/Alias Name:

Birthday:

Gender:

Race:

Authorization

Initials: *

Date: *

What Our Staff is Saying...

"I love the office staff; they are good to me. They always get me a great schedule. I recommend NurSTAT to everyone. Kathy and Debbie are the best."
- Tracy B., CNA

"I love NurSTAT's office employees because they are very helpful with finding positions to work. Amy and Debbie are the best!"
- Donna O., RN

"NurSTAT accommodates me, finds me shifts, and helps me when I need help. The office staff is great. I love Kathy; she fills my schedule according to my needs. I've been an employee for 12 years."
- Sheila W., LPN

"NurSTAT is a wonderful company to work for. All the girls in the office
are very friendly and helpful. They try their best to work around your schedule."
- Patrice K., CNA